Apologies for the delayed update following an unusually tumultuous few months. As you know, our new practice manager Sarah Wood has been in place for several weeks now and is doing a sterling job, (despite missing out on any overlap/handover). There are a few other pieces of news to pass on:

Automatic Door at PB

After feedback from patients we have upgraded the front door at our Pateley Site to an automatic door which will make wheelchair access much easier.

Recruitment

Like most UK practices, we remain understaffed, but we have some excellent new receptionists and are outsourcing parts of the reception and admin role where possible. We have just recruited a new Healthcare Assistant and a new Practice Nurse, and are increasing our pharmacy capacity through the Primary Care Network. Dr Robinson is now on a permanent contract having done a series of sets of cover for maternity leave. Hence, although we still need more dispensers and receptionists, we are better placed to improve access times than we have been since before the pandemic. We have also made some changes to contracts so as to improve the chances of recruitment going forwards (e.g. permanent instead of fixed term). Dr Austen has been warmly welcomed back from Maternity Leave and we wish Dr Walton all the best as she is shortly to commence hers.

Birstwith Dispensary developments

With increasing patient numbers and higher numbers of prescriptions per patient, the Birstwith dispensary is no longer big enough and dispensers work is spilling over into the back office. We are therefore reconfiguring the space so as to improve workflow and efficiency, and once practical, we are looking forward to the introduction of bar-code scanners which will improve stock control and streamline the process of checking medication. We are especially grateful to dispensers who do more than their fair share of contracted cover as we have been understaffed in this area for 2-3 years.

GP Rotas

The current balance of urgent vs routine appointments seems to be not far off, but we would sooner be able to offer routine appointments more quickly. Online consultations are extremely popular, but of course there remains a balance to be struck as many appointments need to be face-to-face. Demand continues to rise, and we are constantly looking for ways to work more efficiently. Training our reception staff in "Care Navigation" is central to this, but has stalled because of staff shortages: we are working on ways around this which should bear fruit later in the year.

Blood Pressure Machines

Blood pressure is best taken at home as we now know that clinic readings are less reliable. Not every patient has a monitor however, so we have installed DIY blood pressure machines in two of our waiting rooms.

PS24 Medication Vending Machine at Dacre

Increasing numbers of patients are preferring to pick up medication from the vending machine at Dacre as this can be used any time and any day. There is plenty of capacity for more patients to sign up for this service.

1 There is overwhelming agreement that upgrading the disabled access at Pateley Bridge should be prioritised, and this is going ahead as soon as possible.

2 A majority agreed that patients should be seen in order of priority but, perhaps surprisingly, this was not a large majority. We feel strongly that clinical need should determine the order in which patients are seen.

3 Of those who had used the online consultation option, the overwhelming majority felt the new version was an improvement. We will continue to offer this version until a superior option becomes available.

4 Patients felt that a time window of 30-60 minutes was reasonable for a booked telephone appointment. We have been trying hard to improve beyond this target and will continue to do so, but are aware there have been exceptions and have fed back to the relevant clinicians.

5 The majority of patients showed awareness of the national situation with GP recruitment, but nearly a quarter of respondents answered that they only wanted full time doctors at the practice. We will bear this in mind when recruiting, but the trend is for the inadequate (and decreasing) number of doctors who choose General Practice to want to work part-time, and for existing GPs to reduce their hours and take on other work. For GPs, "full-time", (excluding any out-of-hours work), equates with around 60 hours/week, and often there are many unpaid extra hours of course. The President of the Royal College of General Practitioners has recommended a maximum of half time in order to avoid "burnout", so for the trend towards part-time working to be reversed, the nature of the role would have to change considerably. If we look back to when most GPs were full-time, there were clear advantages; but demand and workload are much higher now, and there is a better gender balance.

6 A majority were positive about the concept of "skill-mix" provided clinicians were appropriately trained. This year, we have welcomed a new First Contact Physiotherapist, a new Social Prescriber, a Paramedic and a Wellbeing Practitioner. We are also in the process of expanding our pharmacy team.

7 The vast majority of patients were on board with the concept of letting reception staff know enough information to allow the correct care to be arranged, (provided the patient retains the right to choose how much to disclose). This is an important part of ongoing training for receptionists.

8 Nearly a quarter of patients felt we need to prioritise improving the way incoming calls are handled. This is backed by some comments on our website, and although many recent changes have been effective, we are aware it is still a priority issue and are working with reception to improve matters pending a new telephone system. We are also looking into an option of sending patients a "link" to enable them to book their own appointment without having to "queue" on the 'phone.

9 An overwhelming majority were not in favour of practices being taken over by acute trusts: nor are the partners, and we will continue to resist moves towards this.

10 An overwhelming majority were keen that the practice does not sell our buildings to a commercial institution.

Below is a brief update following a recent PRG meeting

Current challenges:

1) We are aware that there is an excessive wait for a routine telephone consultation despite our now finally back to a full compliment of doctors and nurse-practitioners. We are therefore changing our schedules once again to accommodate additional appointments and to streamline the use of online consultations.

2) We continue to struggle with recruitment for receptionists, cleaners and dispensers (please spread the word) and this is having a knock-on effect on our receptionist training: because everyone is needed to cover the 'phone calls, training is delayed at a time when we need it most due to rapid changes. We continue to advertise however, and have plans to fit in training around active work.

3) The hospital backlog is very considerable and is causing a great deal of upset to patients who are waiting many months for operations and appointments. This has a knock-on effect on the practice as patients tend to contact us about it rather than the hospital.

4) The accelerated changes to the way UK primary care works have caused additional strain on patients and the practice alike. While many patients are delighted with the changes (e.g. online consultations, remote management, direct access to physiotherapist, social prescriber, pharmacist etc) others ask why things can’t go back to how they were "in the good old days". We still have some patients who refuse to see a Nurse Practitioner.

This last point led onto a discussion about one or two patients who had addressed concerns to members of the PRG regarding e.g. booking a face-to-face appointment. These have always been provided whenever needed at all three sites, and several months ago we added something to our telephone message specifically confirms that anyone needing a face-to-face appointment will be offered one. However, this is not how some patients perceive things and we discussed the reasons for this. Sometimes, when a request is met with "yes, but we'll need to arrange a telephone call with a clinician in order to prioritise your appointment", what the patient hears is "No". This messaging problem is something we are looking at and links with the earlier issue of reception training. It is a national matter, not helped by the media quoting the smaller proportion of appointments now being Face-to-face, yet failing to explain that this is mostly because practices are offering so many more alternative options.

One PRG member had asked about data to show the trend of over all patient contacts since before the pandemic. We have checked this and the trend has been a steady rise as expected, with the exception of the first few weeks of the first lockdown when there were fewer contacts for obvious reasons.

The group discussed how we can improve "messaging" accordingly. Ideas included a newsletter, changes to the website, an open day, a questionnaire (to include some information), and improving the "visibility" of the clinicians, (e.g. photographs on the website). We have 10 500 patients (more each year) but not everyone uses the internet so we agreed we need a multi-pronged approach and will discuss the options at the next partners' meeting.

Some other updates:

This week we have seen the return to the practice of one of our senior clinicians for the first time in two years. This has opened up additional capacity for face-to-face appointments. In response to suggestions from the PRG, we are arranging bicycle racks at each site and have ordered a specialist couch for gynaecological examinations which should save some patients having to go to hospital. In response to patient feedback we have changed our online consultation platform to a different provider which seems to have gone down well.

Thanks again for your ongoing support.

Dear all, by way of an update, we are working hard to improve the waiting times for appointments. There have been some misleading and confusing headlines around recently, so please see below for some explanations:

Q: Why aren't things back to normal?
A: Cases of COVID locally are higher than ever, so infection control measures are essential. These include staggering the use of waiting rooms, cleaning between patients and wearing PPE, all of which reduce the rate at which we can work. Staff absences remain high due to COVID, (self-isolating and illness). The national recruitment/retention crisis is affecting us significantly.
All of these factors will improve, but what seems unlikely to change is the popularity of remote consulting for many patients, (especially econsultations, despite their limitations): over all there are many more consultations than ever before and we see no sign of demand reducing.

Q: Why do I have to contact a clinician before I can book a Face-to-face appointment with a GP or Nurse Practitioner?
A: We need to make sure patients are seen in order of need, especially while demand is so high.

Q: How come there is such a long wait for a telephone appointment?
A: We have increased the number of telephone appointments but the demand is extremely high and we are working on a solution. We are meeting again next week regarding this problem.

Q: Will the Government investment plan help us at NGP?
A: We hope so. Funding for additional hours over Winter often happens, but it is yet to be seen whether this year's version will be more effective than usual as the details have not been provided. The Government's broader plan is for patients to see pharmacists, physiotherapists etc more and more as GP numbers continue to fall steadily.

Q: Why has staff turnover increased?
A: As well as the impact on patients, the changes brought about by the pandemic have had a negative effect on the NHS workforce (which has not been spared the national recruitment and retention crisis). We have always run to some extent on good will, with many working more out of duty than for the pay. Our reception staff and dispensers especially are exhausted after covering for additional sick leave etc and, like everyone, they are working harder than ever. Added to this, understandably angry patients sometimes take out their frustration on frontline staff (although the vast majority have been grateful, understanding and polite).
We are working on further improvements to the rotas and any other changes we can make to improve access. Many thanks for your support and patience.

General Practice is Changing (but it's not all negative)

Understandably, some patients have asked "why can’t we go back to the good old days when we could call reception and book in with a GP in a short time-frame, and now I have to justify my request and wait weeks".

The pandemic is only part of the explanation, (by which I mean the need to restrict crowding in the waiting room, the need to clean rooms between patients, the need for PPE, the staff shortages due to self-isolation, illness, bereavement, or vulnerability of staff members).

The broader factors pre-date the pandemic and are accelerating: demand for care is growing (ageing population and we all rightly demand more), while falling resources are increasingly focussed on larger institutions as the national plan is to "upscale" for economies of scale. The Government wants GPs to "work to the top of their license" and lead a Multi-Disciplinary Team including pharmacists, physiotherapists, Nurse Practitioners, Social Prescribers,  Healthcare Assistants, etc, so the trend of seeing less of one's family doctor is set to continue: our aim is to make this ongoing change less painful than it might be.

But looking back over 20 years, there are lots of positives:

1 Practices receive more oversight: The Care Quality Commission, NHS England, Clinical Commissioning Groups, Primary Care Networks are all new in this period and Clinical Governance has gradually developed, (previously practices could pretty much make their own rules). This has increased our workload, and often grinds us down, but probably helps keep us better in tune with needs of the population.

2 There is now far more patient empowerment rather than patient instruction. This is most important clinically, but is also true of the way we deal with comments and complaints.

3 There is far better equity of care; in the past there could be one level of care for "regulars" and another for the quiet majority.

4 Nowadays far more care is provided by GPs and practice nurses instead of needing a referral. Hospitals no longer employ "general physicians", and there are virtually no planned ("elective") admissions. GPs have ongoing training throughout their careers, constantly acquire new skills and knowledge, and take on new responsibilities. Examples are in-house dermatology reviews, specialist injections, a broader range of contraception choices etc. The basics are also done better due to better Continuous Professional Development, e.g. management of cardiovascular risk, detection and prevention of cancer. All clinical staff are now able to provide lifestyle advice including Health-Care Assistants.

5 We have improved access for younger patients- in the past, teenagers and young adults rarely consulted, but are now encouraged by respect for autonomy/capacity and the use of remote consulting. There is no doubt that the wait for face-to-face appointments can be much longer than ideal, but we have a wider range of access options with extended hours, remote consulting, and the new "Pharmaself24" dispensary vending machine at Dacre, especially popular for e.g. working patients.

6 There is far more attention to mental health, (thank goodness). Twenty years ago, mental illness was only considered a problem if at the most severe end of the spectrum, and our main focus was on medication.

7 There is better care for the vulnerable- "Safeguarding" was an unknown term twenty years ago, and was only extended to adults relatively recently.

8 Appointment times are longer to reflect the increase in complexity of the medicine and the attention to mental health: on average, appointment times have roughly doubled over the last two decades.

9 We now have in-house highly trained "First Contact Physiotherapists", pharmacists, Nurse Practitioners, all working within the practice team alongside GPs.

There remain plenty of areas requiring improvement, (e.g. we are making changes which should reduce the wait for appointments within the next month or so) but it is worth reflecting that the constant change within the NHS is sometimes a positive thing.

Dear all, please find below a brief update on practice developments. 

COVID Changes

The success of the vaccination program has reduced the risk of infection between patients and has allowed us to use the waiting rooms more freely. Naturally we are maintaining measures to allow social distancing and continue to ask that patients and staff wear masks. We are needing a little less time to clean rooms between patients so have been able to increase the number of face-to-face slots, but are continuing to deal with problems remotely where appropriate. We are in the process of making alternative arrangements for cases where there is a higher risk of infectivity (e.g. waiting somewhere other than a waiting room, being seen at the end of a clinic) so that we will no longer need a dedicated "Red Clinic'' at Pateley in the afternoons. This will allow greater flexibility for both COVID and non-COVID patients. Likewise, the need to reserve The Grange as a “Green Site” is less acute and we are looking to changing this soon.

 A reminder about testing: (COVID cases are rising, "it has not gone away")- the national advice to get a PCR test (not just a lateral flow screening test) remains unchanged: this is essential for anyone with a new persistent cough, temperature or loss of taste/smell. This is absolutely critical to minimise spread of COVID between patients in Nidderdale. PCR tests are available online or via 119.

Continuity and Appointments

Linked to the above, we are very keen to improve continuity (ie same clinician deals with a specific case rather than patient having to start afresh) and to improve access (especially for people who prefer F2F) and of course the two needs run counter to each other (ie things which improve continuity tend to delay access, and things which improve access tend to sacrifice continuity). This dilemma is not new, (or local) but has been amplified by the pandemic. Thanks to the vaccine program, we think it is approaching time for an overhaul of the rotas for clinicians, which will hopefully serve to improve both aspects. These should be on stream in September.

Incoming calls

For some years we have had a doctor and a nurse practitioner directly taking incoming urgent calls each morning. For various reasons this has become less efficient and effective, so we have decided instead to use the clinician time to contribute to the general pool of work instead (including returning calls for urgent matters). 

Our Team

Like everyone, our team has been under huge pressure due to very high levels of cover for sickness and self-isolation, soaring demand, manning the vaccination program, changing work practices and loss of holidays. We are blessed with remarkably generous and committed staff and the gratitude and support of patients has been very much appreciated. Our receptionists and dispensers in particular have had to manage a series of changes which we would never have envisaged, and unfortunately have been in the firing line for the understandable dissatisfaction voiced by a minority. Thank you again for your understanding.

Dear all, by way of an update: the vaccination program is going extremely well for Nidderdale patients and as you may know, Yorkshire is ahead of most of the rest of the UK which is in turn ahead of most of the world. This will be a factor in the fall in COVID cases at Harrogate District General, though of course there is a very long way to go.

Our wish to roll out our own local program has not been possible as yet, but there is a new centre open in Ripon. Meanwhile, we continue to contribute to the staffing at the Yorkshire Showground and feedback from our patients has been very positive (“worth the long journey”).

We had a comment recently suggesting that GPs have been more “distant” from patients, so I thought it might help to reiterate why we are having to manage things remotely wherever appropriate. Patients (with and without COVID symptoms) have continued to be examined throughout the pandemic. As well as seeing patients at all three surgeries, we have helped man the “hot sites” for suspected COVID patients, and have been seconded to the vaccine centres. Some clinicians have been unable to see patients due to their own risk level, and some have inevitably been off sick or having to self-isolate. However the main reason for having to manage many cases remotely is that minimising footfall in the waiting rooms reduces the risk of cross-infection between patients. Hence, practices have had to find ways to care for patients remotely wherever possible, including econsults, ‘phone, and video-consultations. Where however an examination is required, a face-to-face appointment is offered.

We will probably never know how many lives have been saved by the changes practices have made to their systems.

As things improve we look forward  to there being more face-to-face consulting: it is certainly preferable for many patients and indeed for clinicians. The remote options will continue however, as they have proved very popular for a wide range of cases.

Thank you once again for your kind comments, support and perseverance through all these changes and those to come; and special thanks once again to all the volunteers who have made such a difference to the care of Nidderdale patients.

Dear all, just a quick further update: as you know, vaccines continue to be provided via the centre at the Yorkshire Showground and we have not yet been allowed to have vaccine to deliver here in Nidderdale. Patients will be contacted by the surgery either by text or ‘phone to book an appointment at The Showground and some patients are also receiving letters from the government inviting them to attend the centres in York and Leeds. Although this can seem chaotic, the rate of vaccination is pleasingly high, and for Yorkshire is probably the highest in the UK. There are inevitable quirks whereby someone at slightly lower risk is given a slot a little before someone else, but that is inevitable given the scale of the campaign. Please be patient: all eligible patients will be contacted.

Practice staff are being seconded to the vaccine centre on a rota basis so I’m afraid our already pared down team is going to be further depleted for the next several months. Service is bound to be affected but we have so far managed to continue seeing patients and dispensing at all three sites while dealing with ever increasing cases by “eConsult” or over the ‘phone.

Econsultations are increasingly popular (roughly 600 per month) and while not suitable for all patients or all cases, are providing very timely access to care and advice for thousands of our patients. One or two have quite rightly pointed out some irritating aspects of the eConsult template (e.g. some unnecessary questions, some resistance to moving forward unless a box is first filled)- certainly these flaws are annoying and we have been promised that the providers of the software are constantly improving things, but I’m afraid we are not able to change it ourselves. We are piloting a competitor product and will swap if it proves superior.

Dear all, we have had one or two comments about difficulty getting through on the ‘phone- please accept our apologies. We have multiple lines available all day and more people answering them than ever, but the volume of calls has been extremely high lately and there is therefore a longer wait than we would want. This was made worse recently by some problems with the lines which meant that the queuing message was not playing; apologies again for this which is now fixed.

It turns out this is an issue for all practices lately, probably related to the pent up need and widespread worsening of mental health resulting from the pandemic. We continue to look at ways of improving our systems to respond to this, and would offer the following tips for those needing to contact the practice:

1 Econsults are the most efficient way to contact the practice and can be accessed through our website. We guarantee a response by 18:30 the following working day.

2 Mornings are the busiest time for the ‘phones, so if your call can be made in the afternoon it might be answered more quickly. Similarly, Mondays and Tuesdays are our busiest days.

3 For urgent clinical matters where you need to see or speak with a healthcare professional about a matter which must be dealt with this day, you can call between 8 and 12:30 and press 1 to go through to a clinician. Please understand that this clinician will only be able to “triage” your call rather than provide a full length consultation as there are other calls waiting. It is always difficult to balance the wishes of the patient on the ‘phone with the needs of those trying to get through.

Dear all, just a brief update as we approach the Winter:

 The option of queuing outside is increasingly unsatisfactory so we have put up posters explaining the options of waiting outside, in a car, or coming into the waiting room. In order to allow social distancing and minimise infection risk we are still having to limit the numbers in each of the waiting rooms of course, so we continue to manage things remotely wherever feasible. We have also erected some shelters where possible, though planning requirements and a failed funding bid have limited our options.

Many of our staff continue to be off sick, are having to quarantine because of Test & Trace, or are unable to see patients face-to-face, but we have managed to continue running clinics at all three sites, and in view of the national fall in cancer diagnoses, we are doing our best to encourage patients to make contact if they have worrying symptoms.

Patients have been asking about options for troublesome excess ear wax where oil drops have failed to help: even before the pandemic, the CCG was keen to reduce dependency on interventional treatment, and both Boots and Specsavers have started providing a private micro-suction which is a safe and effective option. There are now “DIY micro-suction” tools available from Boots or over the internet. After some debate about how safe it is for a clinician to irrigate ears during the pandemic, the hospital is accepting referrals for micro-suction, and we have opened up a small number of slots for irrigation: both will unfortunately be subject to a longer wait than we would like.

Many patients have been pleased with aspects of “tele-medicine”, including the econsultations (a response guaranteed before the end of the next working day) telephone consultations, and video consultations. A particular example to highlight is the management of high blood pressure: it is now well recognised that home blood pressure readings are more valid than clinic ones (ideally a set of readings averaged over a week) and patients are increasingly buying their own machines and submitting readings for our assessment. We also have machines at each site which are available to borrow.

The flu campaign has been especially challenging this year for various reasons, but thank you for all the positive feedback about how well the clinics have been running so far, and thanks again to Nidderdale Plus for co-ordinating the superb volunteers. The government instructed that we vaccinate the more vulnerable groups first, and the CCG were planning to run their own clinics for the 50-65 year old patients, but we understand we might after all be asked to do these in due course so please watch this space.

The pandemic will not go on for ever!

All the very best,
Dr John Hain

(on behalf of Nidderdale group Practice)

The pandemic has brought all manner of suffering to our patients, including bereavement, hardship, morbidity and anxiety. The practice has had to change considerably, and will continue to do so, but our priority remains providing excellent care in Nidderdale.

Why are face-to-face appointments being restricted?

Where a face-to-face appointment is necessary this will always be provided. In order to minimise risk to other patients and indeed to practice staff, we are trying to minimise footfall at the surgery, so if a consultation can be managed remotely, (econsultation, phone-call, video) that is preferred. As well as reducing risk, this system is more efficient for patients and staff and has generally reduced our response times.

I don’t have internet access- does this mean I can’t get a consultation?

No. Plenty of patients do not use the internet and we will always cater for this. The efficiencies afforded by some patients using the internet improve the service we can offer to all patients: thanks to the high use of econsultations etc, the wait for other appointments has reduced.

Why can’t we use the waiting room as usual?

A crowded waiting room could allow cross infection and for vulnerable patients that could be fatal. Somehow therefore we have to learn to operate without more than three or four patients in the waiting room at once. This has been just about possible so far thanks to the large volume of “remote consulting”, but as demand increases (inevitable over the Autumn but actually already is at its highest for many months) and the weather gets worse we recognize that it will become increasingly challenging. Please see below.

How can you expect us to wait outside in the cold?

We don’t want anyone waiting out in the cold. If it is cold or wet and there are already people in the waiting room, (we are trying to avoid having too many parallel clinics) please let us know if you would rather wait in your car. As soon as possible we hope to have shelters built at the various entrances.

Do GPs still do visits?

In Nidderdale the answer is yes. Video-consultations often provide an alternative so there are fewer visits required than before, but if a visit is necessary it remains an option. As well as taking time, home-visits carry a risk of spreading COVID, so are only made when strictly necessary.

Why do you have a triage system every morning?

Even before the pandemic, triaging has been a useful way for us to prioritise. This is needed because there is limitless need but limited resource.

Why is there sometimes a longer wait for an appointment for a nurse or health-care assistant?

Even when we are fully staffed, there are fewer appointments available currently because we have to change PPE and clean rooms/equipment between patients and cannot allow accumulation of patients in the waiting room. This is also true for Nurse-Practitioners and GPs.

What are all the doctors doing when not seeing patients?

Nowadays GPs have very many ‘phone calls, video consultations, econsultations as well as the face-to-face work. On top of this there are home visits, results to interpret and file, investigations to organise, referrals to make, hospital letters to read, training other Drs, answering medication and dispensary queries, infection control, learning together, supporting the staff and, (for some) running the business.

I'm worried I've got cancer but don't want to go to the surgery/ hospital due to COVID-19

Please do get in touch if you are worried about cancer, (e.g. a new breast lump, changing skin mole, blood in your stool or urine or a change in your bowel habit over the age of 60, unintentional weight loss, coughing up blood etc). We have systems in place to minimise COVID risk, and it is essential that cancer diagnoses are not delayed. We have continued to do smear tests for high risks patients throughout the pandemic and have added extra smear clinics in the last few months to work through our waiting list of patients due a routine smear who have never had a previous abnormal smear. We would encourage you to attend for your smear as normal and to book this with us.

Is the practice focussing too much on protecting staff?

The Pandemic could still present an existential threat to the practice: should our staffing levels fall sufficiently, we would be at risk of having to close. Minimising footfall at the surgery reduces this risk, but of course there is a balance to be struck. Staff are having to keep distant form each other and in some cases work from home to reduce the risk of having to quarantine in the event of a colleague testing positive. Like all businesses, we have had high levels of absence over the pandemic, and there is no prospect of this improving any time soon.

When is it going to go back to normal?

The pandemic is on the rise so none of our safety measures can logically be relaxed as things stand. One or two patients have pointed out that pubs are managing to provide “business as usual” and ask why can’t General Practice do the same: the reason is that by definition, patients are more likely to have infections and more prone to become seriously ill or die than those who are entirely fit and well. On top of this we carry out infection-prone procedures (which would be very out of place in public houses), so our infection control procedures are naturally rather more involved.

Is Nidderdale Group Practice going to merge with the town practices?

We continue to resist merging with the town practices as we feel Nidderdale is unique and benefits from a dedicated local practice.

In Conclusion

Despite having fewer staff, higher demand, and considerable constraints on our way of working, we have manged to keep all three sites open and are dealing with most problems more quickly than before the pandemic. Patients and staff alike are understandably stressed, anxious and frustrated, but we are all in this together and the practice is here for its patients. Many thanks for your ongoing patience. Here’s hoping for an effective vaccine soon.